3. Literature Review
3.1 Low Fertility in the 20 th Century
3.1.2 Pronatal policy
國
立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
individual-oriented institutions (i.e. education and market employment) and family-oriented institutions (e.g. social security, the industrial complex). In advanced modern societies, he claims, gender equity is high and rising within education systems and the much of the labor force. That said, the traditional male breadwinner model still prevails as the foundation of many family-oriented institutions, and if children are present, obliges women to be caretakers and men economic providers within traditional heterosexual relationships (McDonald, 2002).
Childbearing limits the increased economic and career opportunities afforded to women by rising gender equity, and women likewise limit their fertility. This theory of fertility explains the low fertility of traditional patriarchal societies such as southern Europe and Japan well, where there is a large discrepancy of gender equity between individual and family systems.
3.1.2 Pronatal policy. The prevalence of low fertility over the past half century has led to
a variety of pronatal policies intended to stabilize population growth. Pronatal policies may be divided into two kinds, nonmaterial and material incentives for childbearing.
Nonmaterial pronatal policy. Nonmaterial pronatal policy promotes fertility through
nonfinancial channels, and falls into distinct categories: anti-discrimination legislature,
restrictive fertility legislature, or values reeducation programs. In general, these policies provide broad legal support for combining employment and family, or for social changes conducive to increased childbearing. McDonald (2002) describes several options in the policy toolbox to address low fertility. Antidiscrimination legislation preventing unfair hiring practices based on gender, relationship, or family status supports the growth of economically sustainable families, as does guaranteed maternity and paternity leave with full or partial benefits. Policy ensuring a parent’s return to work after childbirth guarantees some economic stability for new families;
some policies may even allow a part-time return to work with continued partial benefits.
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
Parental leave policy immediately raises questions about who pays leave benefits, what the criteria are for receiving those benefits, and how long of a leave period is guaranteed. That said, parental leave policies may help people reconcile work with family, and gender-neutral policies may even encourage greater gender equity in childrearing responsibilities (McDonald, 2002). European evidence in France and former East Germany shows that role incompatibility for working mothers has had a significant impact on fertility (Legge Jr & Alford, 1986), and that parental leave policies were correlated with higher fertility in Canada, Finland, Norway, and Sweden (Gauthier, 2007). Rindfuss and Brewster (1996) find, however, that in the United States, research from the latter half of the twentieth century suggests that maternal leave policies and cash benefits did not promote childbearing in the absence of other family policy. Thus while parental leave policy is associated with more stable fertility among low fertility countries, evidence remains mixed as to its effect on fertility in isolation.
Values reeducation ties back to the second demographic transition / post-materialist approach to low fertility and would (hypothetically) involve governmental support for programs to reshape citizen’s attitudes towards family size. Demeny (1986) argues that pronatal values reeducation is not an appropriate route for politically developed countries, given that:
Democratic states are ill-equipped to engage in specialized value education of their citizens: values are embedded in and conveyed by the deeper institutional
structures…Ministerial exhortations, posters of happy three-child families, and medals to heroine mothers are neither well-received nor effective in influencing fertility (p. 347).
On a similar note, restricting access to contraceptives, abortion, and other family planning methods presents an illiberal approach to pronatal policy unsuitable for modern democracies. In countries where contraceptive knowledge and use has already become widespread, and where the
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
internet enables rapid communication, such retroactive measures may not be possible.
Furthermore, evidence from Legge Jr and Alford (1986) in Romania indicates that abortion restriction is both unlikely to raise fertility and very likely to harm the health of women and children. After World War II, many Eastern European countries promoted population policy to combat fears about a diminishing labor force and regional population distribution; Romania accomplished this through extreme abortion restriction and childlessness taxes. In general, for Eastern Europe in the 1950s-60s, birth control access was rarely available, and abortion and the pullout method were the primary means of birth control. The Romanian case demonstrated that in the absence of legal family planning methods, women turned to illegal abortion to prevent births, with severe health consequences. Moreover, results show that the economic incentive structures of contemporary Hungary and former East Germany had a more lasting positive effect on birthrate in those regions.
Material pronatal policy. Financial incentives for childbearing span a wide range of
options, from direct cash infusions for new parents to subsidized goods and services for family support. Cash-based pronatal policy uses direct monetary incentives to motivate limited
childbearing among women and couples. In a broad review of thirteen macro-level studies on family cash benefits and fertility, Gauthier (2007) concludes that in general, higher child benefits (of any of these material policy types) are associated with higher fertility among a diverse range of methodologies. However, she asserts that these aggregate studies show that cash benefits are more likely to affect birth timing than completed fertility, and proposes they may only speed up the timeline of childbearing decisions. Micro-level data reviewed also supports the correlation between child or family benefits and fertility, but with inconclusive results regarding magnitude of effect on birth order.
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
Specifically, material incentives may include financial assistance measures like periodic or one-time birth benefits, and tax exemptions for parents. Periodic payment schemes provide regular cash transfers for parents by the state, depending on the age of the child or its birth order.
A key flaw of such policies is reliance on the assumption that the household equally shares income and childrearing responsibility, and failure to address the role of gender equity in the family. The state similarly might dispense one-time child benefits to parents, usually paid upon the birth of a child or at another, significant age (for example, when the child begins school).
Both of these types of redistributive policy are intended to increase horizontal equity by
supplementing parental income in recognition of the cost of having and raising a child (Demeny, 1986; McDonald, 2002).
Tax deductions, exemptions, or credits given to parents are another form of redistributive fertility policy. Whittington, Alm, and Peters (1990) examine implicit pronatalism in U.S.
income tax personal exemptions for dependents, showing that personal exemptions led to a significant increase in birthrate for middle-income families. The obvious reason for this type of tax-based pronatal policy is to provide a child subsidy, which offsets the costs of raising a child to adulthood. In the Whittington et al. (1990) study, all specifications demonstrated that the personal exemption policy had a positive and significant impact on birthrates in the U.S. Even stronger evidence of a pronatal effect from tax incentives comes from Canada, in analysis of the Quebec Allowance for Newborn Children policy. Milligan (2005) shows that women eligible for the maximum child benefit (C$8000) increased their fertility by 16.9%, and women on average increased childbearing by 12%. Milligan reconciles these findings with previously inconclusive or weak findings from U.S. welfare literature by interacting income with the policy dummy, finding a strong income effect that indicates unexplained heterogeneity in the sample. He
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
hypothesizes that the stronger relationship between policy and childbearing for higher income women may be tied to the higher incidence of planned births in that income bracket, for which previous studies failed to acknowledge.
Besides direct monetary transfers or tax savings, another form of material incentive for childbearing is subsidized goods or services for children and the family. Housing subsidies (via periodic, one-time, or tax-based payments) may contribute to a sense of economic security that encourages childbearing. In most economically developed countries, public education systems offer free schooling for children until adulthood, and these may also be considered subsidized child welfare services. Many contemporary studies on fertility and material pronatal policy focus on childcare availability, with mixed results (Gauthier, 2007). The French, Norwegian, and Swedish governments have famously taken this approach via subsidized nursery schools (McDonald, 2002). In Norway, Rindfuss et al. (2010) find that increasing publicly subsidized childcare not only speeds up birth timing, but also increases overall levels of childbearing.
Further, they find that childcare availability could increase fertility by up to 0.5-0.7 children per woman; or, put another way, if the results of this study are generalizable to other
sub-replacement fertility countries, increasing public childcare from 0% to 60% availability could bring total fertility back up to replacement level. In Japan, G. H. Lee and Lee (2014) find that increased childcare availability through the Angel Plan and New Angel Plan (largescale national pronatal policies) between 1971 and 2009 had little effect on fertility. Additionally, they did not find evidence that role incompatibility of working mothers limits fertility, as proposed by Rindfuss and Brewster (1996).
Pronatal healthcare policy. Healthcare and medical insurance policies fall into the category of material incentives for childbearing, since they function by lowering the monetary
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
cost of children in a similar fashion as tax credits or cash payment systems do. Analysis of the RAND Health Insurance Experiment in the U.S. by Leibowitz (1990) shows that women
randomly assigned to free medical care for 3-5 years evidenced a 29% higher birthrate than those assigned to cost-sharing insurance. This study indicates a pronatal effect of medical care
programs, but notes that this effect may speed birth timing in the short term rather than increase fertility in the long run. In the United States, there is a robust literature on the state-sponsored low-income health insurance program known as Medicaid. Between the 1980s and early 1990s, significant reform of Medicaid enrollment criteria doubled eligibility rates for women 15-44 in the United States, extending coverage of prenatal care and child healthcare regardless of family structure and other limiting factors (Zavodny & Bitler, 2010). According to standard fertility theory, decreasing the cost of childbearing and childcare should increase fertility; analysis of panel birth certificate and U.S. census data reveals only weak fertility effects of Medicaid reform, however.
Zavodny and Bitler (2010) explore the effect of Medicaid eligibility expansion on
birthrate through OLS regression, disaggregating results by maternal race (white and black only), educational attainment, and marital status. They find that the expansion had little substantial effect on overall fertility during the period 1982-1996, and a 1% increase in eligibility was associated with a statistically significant but small 0.9% increase in birthrate for white women (a 0.3% birthrate increase in the black sample was statistically insignificant). This small boost in fertility was significant and larger among less-educated white women (those without a high school diploma). The pronatal effects of increased eligibility were generally larger for unmarried or less-educated women as compared to married, women with beyond a high school education in either racial group—but those results were found to be largely statistically insignificant at the
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
10% level. Looking specifically at enrollment expansions between 1987 and 1991, Joyce, Kaestner, and Kwan (1998) find that raising the income ceiling for Medicaid enrollment increased birthrates among white American women by 5%, with no significant effect among black women. Though pronatal effects of Medicaid were found after eligibility expansion, increases in birthrate were only statistically significant for certain demographic groups.
Further Medicaid analysis by DeLeire, Lopoo, and Simon (2011) using state fixed-effects modeling find a small but positive relationship between Medicaid eligibility expansions in the 1980s-90s and births, using state birth count as the dependent variable. A 1% increase in eligibility correlated with a 1.2% increase in births for white women, and 2.4% increase for black women. These results were not robust to state and year fixed effects across cells disaggregated by race, maternal age, education, and marital status, though, and once fixed effects were introduced the magnitude of any fertility effect often decreased to a trivial extent. Both of the above studies conclude that there is no robust relationship between recent Medicaid eligibility expansion and childbearing patterns in the United States.
Similar research on a 2005 U.S. insurance mandate reform by Schmidt (2007) analyzes the effect of increased coverage of infertility services on fertility rates, under the same premise that decreasing the cost of health services could stimulate usage of those services, and thus, increase childbearing. Difference-in-differences modeling on birth certificate and U.S. census data finds that mandate states were associated with a small negative effect on birthrate overall (with a coefficient of -0.05). The presence of an infertility mandate increased first birth rates for white women 35 and older by 8%, significant to various robustness tests. But like DeLeire et al.
(2011), once control variables (including demographic and geographic information) were introduced into regression, no significant effects of the mandates were found for any of the
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
women in different age or racial groups. These studies are in line with the larger literature on the fertility effects of Medicaid and other insurance reform in the U.S.; while they seem to imply some positive correlation between health insurance and fertility, they also indicate that this relationship is either weak or not well understood.
Relatively fewer studies have approached the potential pronatal effects of healthcare policy outside of the United States. Nakajima and Tanaka (2014) determined that subsidized health checkup services increased the probability of couples having at least one child in Japan.
Their results show that a 10% increase in state expenditure for health checkup services increases the probability of a couple having a child by 0.5-0.9%. In Korea, S.-S. Lee (2009) similarly finds that introduction of the state-sponsored “health and nutrition system” supporting maternal and child health as part of the First Basic Planning for Low Fertility and Aged Society policy, had a positive effect on first and second-order birthrate in logistic regression in 2007. Other sections of this major population policy, such as maternal labor law reform and childhood educational reform, also had positive fertility effects during this period.
Debate continues over the usefulness of fertility policy, nonmaterial and material alike.
Population scholars, including Paul Demeny (1986, 2005) and Anne Gauthier (2007), argue that policy is more likely to affect fertility timing than completed fertility; they further claim that the types of pronatalist policy acceptable to liberal developed cultures is often expensive and
ineffective. The literature on pronatal policy and fertility remains inconclusive, in part because such policies often combine financial incentives for childbirth with non-cash incentives, making it difficult to pinpoint which program, if any, stimulated fertility. For example, in Frejka and Zakharov (2013), results show that two waves of comprehensive pronatal policy in Russia (during 1981 and 2007) that included material and nonmaterial birth incentives both failed to
‧
國立 政 治 大 學
‧
N a
tio na
l C h engchi U ni ve rs it y
promote domestic fertility. Did none of the policies, from parental leave, to maternal capital, to child cash benefits, have any effect on domestic childbearing decision-making? Because of the bundling of cash and noncash benefits, it is difficult to compare the effectiveness of the
individual policies from historical analysis alone.
Analysis of the fertility effects of healthcare policy implementation or reform, on the other hand, often benefits from the availability of information about timing and benefits of individual policy changes. In addition, policy initiatives like Medicaid eligibility reform or Taiwanese NHI implementation affect a large portion of the population in a relatively short period – this lends itself more readily to empirical assessment.